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Third coronary artery bypass operations: risks and costs
B W Lytle1, J L Navia, P C Taylor
1Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Ohio 44195, USA.
Insights
Third coronary artery bypass operations carry increased risk, especially for patients 70 or older. However, outcomes for younger patients are favorable, with manageable hospital costs. This highlights age as a key predictor of success.
Area of Science:
- Cardiovascular Surgery
- Cardiac Reoperations
- Outcomes Research
Background:
- Third coronary artery bypass grafting (CABG) is a complex procedure with elevated risks.
- Identifying factors influencing outcomes is crucial for patient management.
Purpose of the Study:
- To analyze the outcomes and costs associated with third isolated coronary artery bypass operations.
- To identify preoperative and operative variables affecting patient results and healthcare expenditures.
Main Methods:
- Retrospective review of 469 patients undergoing a third isolated CABG.
- Univariate and multivariate analyses to assess risk factors and cost determinants.
Main Results:
- In-hospital mortality was 7.0%, significantly higher in patients aged 70+ with severe symptoms (14%).
- Long-term survival rates were 94% (1 year), 84% (5 years), and 66% (10 years).
- Advanced age (≥70), poor left ventricular function, and diabetes predicted decreased late survival. Mean costs were 21% higher than primary CABG, influenced by outliers and female sex.
Conclusions:
- Preoperatively identifiable factors, especially age ≥70, are linked to unfavorable outcomes in third CABG.
- Patients under 70 experienced low in-hospital mortality and favorable long-term survival.
- Increased hospital costs are primarily due to a few high-cost cases and are unpredictable.
Background:
Third coronary artery bypass operations are technically difficult and are associated with increased risk.
Methods:
We reviewed the cases of 469 patients who had undergone a third isolated coronary artery bypass operation and used univariate and multivariate testing to examine the effect of preoperative and operative variables on outcome and costs.
Results:
The in-hospital mortality was 7.0% (33 patients). Advanced age and severe symptoms were found to increase risk (both p < 0.05): the mortality was 14% (n = 74) in patients 70 years old or older who had severe symptoms. However, the overall mortality for 1993 through 1995 was 4.3% (5/117) and only one death (1.3%) occurred among the 79 patients who were less than 70 years old. The late survival rate was 94%, 84%, and 66% at 1, 5, and 10 postoperative years, respectively, and predictors of decreased late survival were advanced age, abnormal left ventricular function, and diabetes (all p < 0.05). Again, age of 70 years or more was a predictor of a poor outcome. Only 52% of patients in that subgroup (including both early and late mortality) were alive 5 years after operation. Analysis of direct hospital costs showed that the mean costs of third coronary artery bypass operations were 21% higher than the mean costs of primary operations but that the elevation in the mean costs for third operations was related to very high costs in 4 patients. Sex was found to influence the cost of both primary and third operations (increased cost for women).
Conclusions:
Unfavorable outcomes after third coronary artery bypass operations have been associated with preoperatively definable variables, particularly age of 70 years or more. The in-hospital mortality in patients younger than 70 was low, and long-term survival in this group has been favorable. The increased hospital costs associated with third operations are related to high costs in only a few patients and have been unpredictable.